Understanding trends and variation in paediatric fracture management in England
11 November 2024
Foreword
In this report we have taken paediatric Emergency department (ED) attendances (0-16yrs old) across England (2019-23) and looked at a select number of paediatric fractures where either national guidance or published/emerging evidence suggests limited intervention, imaging or follow up is required. These include clavicle (collarbone), forearm and toe fractures. Given our results we believe future UK wide analysis of other fracture types and/or a wider age range (Adults) may prove beneficial.
For paediatric fractures regarded as minor or ‘low need’, our analysis demonstrates:
If the number of follow up appointments was reduced to the lowest quartile of English Trusts circa. 30,000 appointments could be saved annually. (Slide 40 & 49)
Many clavicle fractures, commonly accepted to heal without intervention, have two or more follow up appointments when evidence suggests none are required. (Slide 23 & 41)
Marked variance exists across Trusts in the proportion of fractures with follow up and how that occurs (virtual vs face to face). (Slide 39-40)
Our analysis demonstrates between 2019-23 the proportion of forearm fractures manipulated:
Our data shows that forearm fractures are the most common fracture in children and in 2022-23 alone over 25,000 had no follow up (Slide 23). Along with the forearm manipulation data this collectively suggests a fundamental change in forearm fracture management has occurred across England, likely driven by Get It Right First Time (GIRFT) targets and recent/ongoing research (FORCE & CRAFFT).
Lastly, our analysis suggests marked regional variation in fracture incidence exists (Slide 13) and is unaccounted in the current GIRFT/Model hospital ‘Wrist manipulations in theatre’ dataset. We have formulated an alternative and potentially more nuanced version accounting for regional variation. Interestingly, Trusts currently considered either in the top or bottom quartiles markedly change position within our proposed model (Slide 43-44).
In conclusion we believe our analysis can help set future GIRFT targets driving change and savings across the NHS.
Dr Patrick Aldridge, Consultant Paediatrician, Paediatric Emergency Department Clinical Lead at NHS Frimley Health Foundation Trust
Report summary
This report sets out to understanding the opportunities to reduce hospital activity through wider adoption of more conservative management of selected paediatric fractures.
The work was funded by NHS England as part of the New Hospitals Programme.
This work may provide an opportunity to create a new activity mitigator in the NHP model to allow trusts to estimate the impact of adopting conservative management of certain paediatric fractures on their future activity levels.
Key findings:
Over the last 5 years there has been a trend towards more conservative management of paediatric fractures, but further activity savings that could be made.
While nationally manipulations in theatre have decreased in recent years, at some trusts there is still scope to reduce the proportion of forearm and elbow fractures manipulated in theatre. This could further half the number of elbow and forearm manipulations performed in England.
There is scope to reduce the number of x-rays for clavicle and toe fractures in emergency care in England by almost a fifth.
There is scope to reduce the number of follow-up appointments for elbow, forearm, clavicle, tibia/fibula and toes fractures in England by a third.
Background
Epidemiology of paediatric fractures
One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year1. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity1.
Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures2. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100, 000 children).
The total fracture incidence rate in the UK was found by one study to be 1,370 fractures per 100,000 children3, while another found the incidence of distal radius fractures to be 337 fractures per 100,000 children at one UK trauma centre4.
Paediatric fracture management
British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement5.
The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up6.
One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as the use of x-rays did not influence fracture management or add valuable information to clinicians’ assessment7.
- Baig MN. (2017) A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age. Cureus. 28;9(8):e1624
- Marson BA et al. (2021) Trends in hospital admissions for childhood fractures in England. BMJ Paediatr Open. 10;5(1):e001187
- Moon RJ et al (2016) Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom. Bone. 85:9-14
- Mamoowala N et al (2019) Trends in paediatric distal radius fractures: an eight-year review from a large UK trauma unit. Ann R Coll Surg Engl. 101(4):297-303
- Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources
- Perry DC et al. (2022). Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet; 400(10345):39-47
- Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304
Background (continued)
Manipulation of paediatric fractures
A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of theatre time a year had been used for manipulation of forearm fractures between 2016 and 20191. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulations being performed in theatre. If the number of fractures manipulated in theatre at all trusts was reduced to the level seen in trusts with well-developed emergency department manipulation protocols there would be an 80% reduction in manipulations in theatre, reducing theatre time for forearm/wrist fractures to under 57 weeks.
Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found that the implementation of these guidelines resulted in 86% of distal forearm fractures in children being manipulated in the emergency department, an increase from 32% prior to the COVID pandemic2. This saved approximately 63 hours of theatre time in the six-month study period.
The GIRFT report did highlight reluctance to perform procedures in the emergency department because of worries about breaching the 4 hour emergency department treatment target, a lack of space/facilities to perform sedation and a lack of familiarity with techniques1.
- Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
- Fink BE etal (2023) Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines. Cureus. 15(7):e41325.
Aims
Add to the information in the literature on the incidence rate of various paediatric fractures (forearm, elbow, clavicle, tibia/fibula and toe) recorded in emergency care in England.
Understand the trends in management of these fracture types over time, e.g. have changes in guidance during COVID-19 changed the trends in management of fractures in emergency care.
Investigate the variation in management of these fracture types between trusts, and the potential activity savings if there was more widespread conservative management, such as reducing unnecessary follow-ups appointments and manipulation in the emergency department rather than in theatre.
Data sources and Study population
The study population included all those aged 16 and under who attended an emergency care centre in England between April 2019 and March 2024 and had a SNOMED code for a closed fracture of toe, clavicle, elbow, forearm or tibia/fibula recorded (see Appendices A-C for full code lists).
Records at a patient level were taken from the Emergency Care dataset (ECDS) and linked with any subsequent fracture related activity recorded in the Outpatient (OPA) and Admitted Patient Care Episode (APCE) datasets in the 3 months post-emergency care attendance. All data were accessed through the National Commissioning Data Repository (NCDR).
This study focuses on closed fractures as this is where there is scope for more conservative management; open, pathological, osteoporotic and birth trauma fractures have been excluded, alongside fractures of the great toe, which should all be followed up.
Incidence rates were calculated using the Office of National Statistics (ONS) mid-year population estimates by age and sex1.
The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. For example, we cannot identify buckle fractures, which we know could be treated more conservatively. However, we could calculate the proportion of children with each fracture type that:
- had a fracture manipulated in theatre (only includes closed manipulations; those requiring internal fixation and re-manipulations are excluded)
- had a fracture manipulated in the emergency department
- received a follow-up outpatient appointment
- had a referral/appointment for physiotherapy
- had an X-ray in the emergency department
Full details of the coding used to identify these procedures/attendances is included in Appendix D.
- https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland
Incidence rates
Incidence rates were calculated to get a better understanding of the the scale of paediatric fracture attendances in emergency care, including
trends over time
the most common fracture types, and how these vary by age and sex
Variation by region to determine whether there may be a greater burden of fractures in some ICB areas
These incidence rates are not the incidence of fractures, but should be considered as the incidence of a recorded emergency care attendance for the specified closed fracture types.
The crude annual incidence rates per 100,000 children were calculated using ONS mid-year population estimates, broken down by age and sex.
Characteristics of the cohort
| Clavicle (N=73,303) | Elbow (N=103,958) | Forearm (N=347,472) | Tibia/Fibula (N=65,368) | Toe (N=69,797) | Overall (N=659,898) |
|---|
Sex |
|
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|
|
|
|
Female | 22,462 (30.6%) | 47,294 (45.5%) | 135,026 (38.9%) | 26,375 (40.3%) | 28,358 (40.6%) | 259,515 (39.3%) |
Male | 50,650 (69.1%) | 56,397 (54.2%) | 211,579 (60.9%) | 38,820 (59.4%) | 41,312 (59.2%) | 398,758 (60.4%) |
Missing/Unknown | 191 (0.3%) | 267 (0.3%) | 867 (0.2%) | 173 (0.3%) | 127 (0.2%) | 1,625 (0.2%) |
Age |
|
|
|
|
|
|
0-4 yrs | 19,718 (26.9%) | 25,978 (25.0%) | 43,446 (12.5%) | 29,284 (44.8%) | 3,385 (4.8%) | 121,811 (18.5%) |
5-10 yrs | 22,129 (30.2%) | 50,687 (48.8%) | 161,671 (46.5%) | 14,097 (21.6%) | 25,130 (36.0%) | 273,714 (41.5%) |
11-16 yrs | 31,456 (42.9%) | 27,293 (26.3%) | 142,355 (41.0%) | 21,987 (33.6%) | 41,282 (59.1%) | 264,373 (40.1%) |
Ethnicity |
|
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|
Asian or Asian British | 3,844 (5.2%) | 9,155 (8.8%) | 21,846 (6.3%) | 4,368 (6.7%) | 4,342 (6.2%) | 43,555 (6.6%) |
Black or Black British | 1,721 (2.3%) | 2,163 (2.1%) | 7,200 (2.1%) | 2,113 (3.2%) | 1,745 (2.5%) | 14,942 (2.3%) |
Mixed | 2,291 (3.1%) | 3,663 (3.5%) | 10,748 (3.1%) | 2,477 (3.8%) | 2,226 (3.2%) | 21,405 (3.2%) |
Other Ethnic Groups | 2,050 (2.8%) | 2,970 (2.9%) | 9,725 (2.8%) | 2,142 (3.3%) | 1,781 (2.6%) | 18,668 (2.8%) |
White | 56,194 (76.7%) | 76,296 (73.4%) | 264,921 (76.2%) | 48,088 (73.6%) | 52,964 (75.9%) | 498,463 (75.5%) |
Missing/Unknown | 7,203 (9.8%) | 9,711 (9.3%) | 33,032 (9.5%) | 6,180 (9.5%) | 6,739 (9.7%) | 62,865 (9.5%) |
IMD Quintiles |
|
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|
1- Most deprived | 16,116 (22.0%) | 26,418 (25.4%) | 80,955 (23.3%) | 16,507 (25.3%) | 16,164 (23.2%) | 156,160 (23.7%) |
2 | 13,544 (18.5%) | 20,349 (19.6%) | 66,825 (19.2%) | 12,959 (19.8%) | 13,262 (19.0%) | 126,939 (19.2%) |
3 | 13,904 (19.0%) | 19,029 (18.3%) | 64,685 (18.6%) | 11,835 (18.1%) | 13,021 (18.7%) | 122,474 (18.6%) |
4 | 14,261 (19.5%) | 18,670 (18.0%) | 65,157 (18.8%) | 11,743 (18.0%) | 13,125 (18.8%) | 122,956 (18.6%) |
5- Least deprived | 14,698 (20.1%) | 18,396 (17.7%) | 66,501 (19.1%) | 11,662 (17.8%) | 13,630 (19.5%) | 124,887 (18.9%) |
Missing/Outside England | 780 (1.1%) | 1,096 (1.1%) | 3,349 (1.0%) | 662 (1.0%) | 595 (0.9%) | 6,482 (1.0%) |
Emergency Dept type |
|
|
|
|
|
|
Major Emergency Dept | 57,459 (78.4%) | 81,863 (78.7%) | 259,815 (74.8%) | 54,357 (83.2%) | 44,682 (64.0%) | 498,176 (75.5%) |
Urgent Treatment Centre/Walk in centre | 15,836 (21.6%) | 22,088 (21.2%) | 87,614 (25.2%) | 10,993 (16.8%) | 25,113 (36.0%) | 161,644 (24.5%) |
Mono-specialty Emergency Dept | 0 (0%) | 0 (0%) | 1 (0.0%) | 2 (0.0%) | 0 (0%) | 3 (0.0%) |
Same Day Emergency Care | 8 (0.0%) | 7 (0.0%) | 42 (0.0%) | 16 (0.0%) | 2 (0.0%) | 75 (0.0%) |
Day of ED attendance |
|
|
|
|
|
|
Weekday | 50,917 (69.5%) | 74,537 (71.7%) | 253,259 (72.9%) | 46,088 (70.5%) | 51,859 (74.3%) | 476,660 (72.2%) |
Weekend | 22,386 (30.5%) | 29,421 (28.3%) | 94,213 (27.1%) | 19,280 (29.5%) | 17,938 (25.7%) | 183,238 (27.8%) |
Time of ED attendance |
|
|
|
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|
|
Daytime 7am to 7pm | 62,907 (85.8%) | 87,237 (83.9%) | 301,785 (86.9%) | 55,995 (85.7%) | 61,135 (87.6%) | 569,059 (86.2%) |
Nighttime 7pm to 7am | 10,396 (14.2%) | 16,721 (16.1%) | 45,687 (13.1%) | 9,373 (14.3%) | 8,662 (12.4%) | 90,839 (13.8%) |
Year of ED attendance |
|
|
|
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|
|
2019/20 | 14,565 (19.9%) | 21,103 (20.3%) | 66,577 (19.2%) | 12,711 (19.4%) | 14,953 (21.4%) | 129,909 (19.7%) |
2020/21 | 11,612 (15.8%) | 16,942 (16.3%) | 56,492 (16.3%) | 10,719 (16.4%) | 9,969 (14.3%) | 105,734 (16.0%) |
2021/22 | 16,739 (22.8%) | 21,943 (21.1%) | 82,556 (23.8%) | 14,190 (21.7%) | 15,034 (21.5%) | 150,462 (22.8%) |
2022/23 | 15,119 (20.6%) | 21,840 (21.0%) | 71,844 (20.7%) | 13,740 (21.0%) | 14,604 (20.9%) | 137,147 (20.8%) |
2023/24 | 15,268 (20.8%) | 22,130 (21.3%) | 70,003 (20.1%) | 14,008 (21.4%) | 15,237 (21.8%) | 136,646 (20.7%) |
Incidence rates for England (2023/2024)
Annual crude incidence of attendance in emergency care with a fracture, per 100,000 children
Type | Female 0-4 yrs | Female 5-10 yrs | Female 11-16 yrs | Male 0-4 yrs | Male 5-10 yrs | Male 11-16 yrs | Total |
|---|
Clavicle | 131 | 77 | 62 | 131 | 154 | 250 | 136 |
Elbow | 172 | 284 | 95 | 175 | 271 | 174 | 197 |
Forearm | 270 | 786 | 362 | 273 | 828 | 1,024 | 622 |
Tibia/Fibula | 174 | 72 | 71 | 213 | 76 | 171 | 124 |
Toe | 17 | 125 | 160 | 26 | 142 | 281 | 135 |
Total | 764 | 1,344 | 750 | 818 | 1,471 | 1,900 | 1,214 |
Forearm fractures are the most common followed by elbow fractures.
The overall fracture rate was lowest during the peak of the COVID-19 pandemic (2020/2021) and highest the following year (2021/2022).
Incidence rate by age/sex group
Denominator for calculating incidence rate is the number of children of that age and sex in England taken from the ONS mid-year population estimates, e.g. incidence per 100,000 0-4 year old males.
Tibia/Fibula fractures are most common in those aged 0-4 years.
Elbow fractures are most common in those aged 5-10 years.
In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 years old having the highest incidence of clavicle, forearm and toe fractures.
Most common fracture types (2023/2024)
SNOMED description |
| Number | Percentage |
|---|
Closed fracture of radius (disorder) | Forearm | 48,043 | 35.2 |
Elbow fracture - closed (disorder) | Elbow | 18,613 | 13.6 |
Closed fracture of radius AND ulna (disorder) | Forearm | 17,498 | 12.8 |
Closed fracture of clavicle | Clavicle | 15,259 | 11.2 |
Closed fracture of phalanx of foot (disorder) | Toe | 15,232 | 11.1 |
Closed fracture of tibia (disorder) | Tibia/Fibula | 8,549 | 6.3 |
Closed fracture of ulna (disorder) | Forearm | 4,347 | 3.2 |
Closed supracondylar fracture of humerus (disorder) | Elbow | 3,394 | 2.5 |
Closed fracture of fibula (disorder) | Tibia/Fibula | 3,278 | 2.4 |
Closed fracture of tibia AND fibula (disorder) | Tibia/Fibula | 2,145 | 1.6 |
Closed Monteggia's fracture (disorder) | Elbow | 108 | 0.1 |
Closed Galeazzi fracture (disorder) | Forearm | 65 | 0.0 |
Closed fracture of distal end of radius (disorder) | Forearm | 23 | 0.0 |
Only showing those fracture types recorded 10 or more times
The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.
There are codes available that specify whether a radius fracture is proximal or distal, but these are not used, instead the general code ‘Closed fracture of radius (disorder)’ is used. We have classified this as a forearm fracture but some of these might be proximal radius fractures and therefore more accurately classified at elbow fractures.
Fractures of great toe were excluded as these should be followed up, however <10 codes related to the fracture of the great toe were recorded over the whole 5 year period in England, suggesting that many of great toe fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within our dataset.
Incidence rates per 100,000 by ICB (2023/2024)
ICB | Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total | % of ED attendances w/o diagnosis |
|---|
NHS Cornwall and the Isles of Scilly ICB | 220 | 365 | 1,136 | 177 | 262 | 2,159 | 1 |
NHS Herefordshire and Worcestershire ICB | 201 | 308 | 1,016 | 142 | 269 | 1,934 | 22 |
NHS Shropshire, Telford and Wrekin ICB | 215 | 292 | 971 | 139 | 230 | 1,847 | 24 |
NHS Gloucestershire ICB | 222 | 186 | 1,004 | 183 | 205 | 1,800 | 37 |
NHS Derby and Derbyshire ICB | 185 | 256 | 905 | 169 | 232 | 1,747 | 13 |
NHS Somerset ICB | 195 | 280 | 925 | 150 | 190 | 1,740 | 18 |
NHS Dorset ICB | 188 | 280 | 857 | 145 | 194 | 1,664 | 26 |
NHS South Yorkshire ICB | 192 | 305 | 803 | 169 | 193 | 1,662 | 18 |
NHS Norfolk and Waveney ICB | 198 | 281 | 842 | 167 | 165 | 1,653 | 8 |
NHS Devon ICB | 188 | 262 | 871 | 163 | 150 | 1,634 | 23 |
NHS Black Country ICB | 164 | 304 | 818 | 148 | 144 | 1,578 | 42 |
NHS Sussex ICB | 162 | 241 | 825 | 128 | 171 | 1,528 | 16 |
NHS North East and North Cumbria ICB | 146 | 232 | 748 | 148 | 186 | 1,460 | 26 |
NHS Humber and North Yorkshire ICB | 187 | 213 | 727 | 136 | 162 | 1,425 | 18 |
NHS Lincolnshire ICB | 146 | 214 | 736 | 134 | 187 | 1,417 | 6 |
NHS Coventry and Warwickshire ICB | 174 | 189 | 717 | 146 | 149 | 1,375 | 16 |
NHS Bedfordshire, Luton and Milton Keynes ICB | 132 | 246 | 688 | 110 | 146 | 1,322 | 22 |
NHS Greater Manchester ICB | 140 | 196 | 708 | 114 | 164 | 1,322 | 32 |
NHS Mid and South Essex ICB | 138 | 215 | 660 | 163 | 137 | 1,312 | 6 |
NHS Cheshire and Merseyside ICB | 150 | 221 | 661 | 139 | 141 | 1,311 | 31 |
NHS Hampshire and Isle of Wight ICB | 134 | 231 | 638 | 139 | 125 | 1,267 | 19 |
NHS West Yorkshire ICB | 156 | 200 | 621 | 132 | 133 | 1,243 | 23 |
NHS Birmingham and Solihull ICB | 127 | 236 | 603 | 123 | 142 | 1,232 | 18 |
NHS Bristol, North Somerset and South Gloucestershire ICB | 125 | 226 | 589 | 177 | 91 | 1,208 | 7 |
NHS Nottingham and Nottinghamshire ICB | 131 | 216 | 597 | 150 | 114 | 1,208 | 13 |
NHS Northamptonshire ICB | 144 | 202 | 578 | 97 | 118 | 1,139 | 13 |
NHS Bath and North East Somerset, Swindon and Wiltshire ICB | 145 | 191 | 571 | 116 | 94 | 1,117 | 24 |
NHS South West London ICB | 130 | 111 | 569 | 149 | 141 | 1,101 | 39 |
NHS Cambridgeshire and Peterborough ICB | 146 | 179 | 550 | 99 | 120 | 1,094 | 45 |
NHS Suffolk and North East Essex ICB | 145 | 157 | 523 | 106 | 129 | 1,060 | 27 |
NHS Lancashire and South Cumbria ICB | 122 | 170 | 530 | 124 | 107 | 1,052 | 31 |
NHS Hertfordshire and West Essex ICB | 110 | 150 | 506 | 100 | 113 | 980 | 22 |
NHS Surrey Heartlands ICB | 130 | 162 | 460 | 102 | 115 | 970 | 31 |
NHS Leicester, Leicestershire and Rutland ICB | 99 | 168 | 446 | 128 | 94 | 934 | 2 |
NHS Staffordshire and Stoke-on-Trent ICB | 87 | 121 | 503 | 88 | 125 | 923 | 12 |
NHS North Central London ICB | 92 | 135 | 438 | 107 | 92 | 864 | 34 |
NHS Kent and Medway ICB | 85 | 104 | 440 | 63 | 109 | 801 | 48 |
NHS North West London ICB | 82 | 132 | 393 | 88 | 74 | 770 | 38 |
NHS Buckinghamshire, Oxfordshire and Berkshire West ICB | 84 | 116 | 356 | 78 | 55 | 689 | 39 |
NHS Frimley ICB | 70 | 118 | 327 | 77 | 46 | 639 | 35 |
NHS South East London ICB | 62 | 103 | 293 | 72 | 69 | 598 | 23 |
NHS North East London ICB | 59 | 121 | 276 | 80 | 47 | 584 | 33 |
While lower rates in some areas will be the result of some trusts in those areas not reliably recording diagnoses codes for emergency care attendances there is evidence of variation in incidence rates by ICB. For example, diagnoses rates are high in both the Cornwall and Leicestershire ICB areas, but incidence rates are considerably lower in the Leicestershire ICB area compared to Cornwall.
Proportion of ED attendances with a fracture code (2022/2023)
Percentage of all emergency care attendances for those aged 16 or under where a fracture code is recorded.
Percentage of emergency care attendances with a diagnosis code for those aged 16 or under, where the recorded code is for a fracture.
There is considerable variability between providers in the percentage emergency care attendances where a fracture is recorded. Even when accounting for the different rates of recording diagnoses seen between trusts, the percentage of diagnoses that are fractures varies considerably.
These differences could be due to:
Alternative provision locally, e.g. in some areas there is independent urgent care provision available.
Regional differences in fracture rate, which may be related to levels of physical activity, visitors from out of area and the demographic of the area.
Issues with coding/reporting, including variation in what diagnoses are recorded.
Seasonal trends incidence rate
For all fracture types incidence rates increase in the summer months (June-Aug, highlighted in yellow), likely due to increases in children participating in physical activities.
The incidence rate in Cornwall is higher year round compared to England as a whole. However, in the summer months (June-Aug, highlighted in yellow) the incidence rate in Cornwall increases more than in England as a whole; in Cornwall the summer incidence rate is on average 78% higher than in the winter, whereas for England as it is 66% higher. Therefore some of the higher incidence rate in Cornwall may be as a result of tourism in the summer months.
Only one trust in the Cornwall ICB area provides emergency care and in 2022/23 they recorded diagnoses codes for over 99% of emergency care attendances, so this will be contributing to the higher rate seen in Cornwall, as nationally only 70% of attendances had diagnoses codes recorded in 2022/23.
Summary of analysis of incidence rates
In children, forearm fractures are the most common followed by elbow fractures.
Fractures of tibia/fibula are most common in under 5. Elbow fractures are most common in 5-10 year olds. For older children the fracture rate is higher in boys compared to girls, with boys aged 11-16 years having the highest rates of clavicle, forearm and toe fractures.
There is significant seasonality with much higher fractures rates seen in the summer months, likely related to increased outdoor physical activity.
Incidence rates vary considerably by ICB region and by trust. Some of these differences will be due to issues with coding and reporting of fractures, as the proportion of emergency care attendances without a diagnosis code recorded varies significantly between trusts. However, some of the differences seen between trusts are likely related to availability of alternative provision locally (independent urgent treatment centres or alternative specialist paediatric provision nearby) or due to differences between areas in the patient demographic and in levels of physical activity.
Lack of detailed coding of fractures means some fractures may be misclassified, e.g. it is not possible to determine which radius fractures may be more accurately classified as elbow rather than forearm fractures, and great toe fractures are not specifically recorded.
Exploring fracture management
There have been recent studies and guidance suggesting a more conservative approach to managing paediatric fractures should be adopted. Therefore we set out to consider whether paediatric fracture management has changed over the last 5 years.
We have investigated:
The proportion of fracture that are x-rayed within the emergency department
The proportion of fractures that receive an outpatient follow-up appointment, which could be an outpatient or physiotherapy appointment.
The types of follow-up appointments, including looking specifically at physiotherapy appointments.
The proportion of fractures being manipulated and the trends in manipulations in both the emergency department and in theatre.
Percentage of fractures with a X-ray recorded in the ED
The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.
Percentage of fractures with a follow-up appointment
These data give the proportion of children with fractures that receive at least one follow-up appointment, which could be either an outpatient department appointment or physiotherapy appointment.
Follow-up rates are lower for toe and clavicle fractures, and highest for tibia/fibula and elbow fractures.
In the past 5 years, there has been over a 10% reduction in the proportion of emergency department attendances for clavicle and forearm where a follow-up appointment is given.
Proportion of face-to-face vs virtual follow-up appointments
During the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face significantly decreased, and this reduction in face-to-face follow-ups has been maintained.
Only showing data for the first outpatient attendance
Follow-up outpatient appts with and without procedures
Over the last 5 years the proportion of children with a fracture that had a follow-up outpatient appointment where a procedure was recorded has decreased, especially following COVID-19.
The proportion of follow-up outpatient appointments with no procedures recorded has remained relatively stable over time. Although for tibia/fibula and elbow fractures there was a slight increase in the proportion of these follow-ups at the start of the pandemic which has remained in the post-pandemic.
Only showing data for the first outpatient attendance
Outpatient procedures recorded following ED attendance
Only showing data for the first outpatient attendance and the most common types of procedures
The majority of procedures are related to casts/bandages/splints, and the numbers of these have decreased post-pandemic, as has the number of diagnostic imaging procedures during follow-up appointments. This likely indicates a move towards more conservative management of fractures, and to be expected with an increased proportion of follow-ups being conducted virtually.
There are also some procedures of joint (OPCS code W92) recorded in these outpatient follow-up appointments (this code includes procedures such as: distension of joint, examination of joint including under image intensifier or anaesthetic, chemical or radiation synovectomy)
The number of manipulations recorded during outpatient appointments is extremely small.
It is fairly common for more than one procedure to be recorded.
Number of follow-up appointments (2022/23)
Includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.
| Mean | Median |
|---|
Clavicle | 1.1 | 1 |
Elbow | 2.0 | 2 |
Forearm | 1.5 | 1 |
Tibia/Fibula | 2.4 | 2 |
Toe | 0.6 | 0 |
Percentage of fractures referred for physiotherapy
The percentage of fractures with a referral/outpatient attendance for physiotherapy in the 3-months post-fractures are higher for those with elbow and tibia/fibula fractures, but generally very low for the other fracture types.
Generally the proportion referred to physiotherapy has remained relatively stable, but there is a trend towards an increase the proportion of tibia/fibula fractures referred.
Factors influencing whether a follow-up appointment is given
| Odds Ratio | Confidence Intervals | P value |
|---|
|
(Intercept) | 2.20 | 2.15 to 2.25 | <0.001* |
Sex |
Female | 1.00 |
| Reference |
Male | 1.12 | 1.11 to 1.13 | <0.001* |
Age |
5-10 yrs | 1.00 |
| Reference |
0-4 yrs | 0.96 | 0.94 to 0.97 | <0.001* |
11-16 yrs | 1.15 | 1.13 to 1.16 | <0.001* |
Ethnicity |
White | 1.00 |
| Reference |
Asian or Asian British | 1.05 | 1.03 to 1.08 | <0.001* |
Black or Black British | 1.14 | 1.1 to 1.19 | <0.001* |
Mixed | 1.01 | 0.98 to 1.05 | 0.34 |
Other Ethnic Groups | 1.00 | 0.97 to 1.04 | 0.86 |
Missing/Unknown | 0.97 | 0.95 to 0.98 | <0.001* |
IMD Quintiles |
1- Most deprived | 1.00 |
| Reference |
2 | 1.08 | 1.07 to 1.1 | <0.001* |
3 | 1.03 | 1.01 to 1.04 | <0.001* |
4 | 1.05 | 1.04 to 1.07 | <0.001* |
5- Least deprived | 1.08 | 1.06 to 1.1 | <0.001* |
Department type |
Major Emergency Department | 1.00 |
| Reference |
Urgent Treatment Centre/Walk in centre | 0.96 | 0.95 to 0.98 | <0.001* |
Day of the week |
Week | 1.00 |
| Reference |
Weekend | 1.06 | 1.05 to 1.08 | <0.001* |
Time of day |
Day 7am-7pm | 1.00 |
| Reference |
Night 7pm to 7am | 1.12 | 1.1 to 1.13 | <0.001* |
Time of year |
Autumn | 1.00 |
| Reference |
Winter | 0.94 | 0.93 to 0.96 | <0.001* |
Spring | 0.95 | 0.94 to 0.97 | <0.001* |
Summer | 0.99 | 0.97 to 1 | 0.06 |
Year |
2019/20 | 1.00 |
| Reference |
2020/21 | 0.85 | 0.83 to 0.86 | <0.001* |
2021/22 | 0.79 | 0.77 to 0.8 | <0.001* |
2022/23 | 0.72 | 0.71 to 0.73 | <0.001* |
2023/24 | 0.72 | 0.71 to 0.73 | <0.001* |
Fracture type |
Clavicle | 0.79 | 0.78 to 0.8 | <0.001* |
Forearm | 1.00 |
| Reference |
Elbow | 2.47 | 2.43 to 2.52 | <0.001* |
Tibia/Fibula | 2.09 | 2.05 to 2.14 | <0.001* |
Toe | 0.37 | 0.36 to 0.37 | <0.001* |
Logistic regression was used to determine which variables are independently associated with a follow-up appointment being given. This allows us to identify which characteristics and thus which groups of children are more or less likely to be given a follow-up appointment. An odds ratio of greater than 1 indicates an increased chance of having a follow-up appointment compared to the reference group, while an odds ratio below 1 indicates a reduced chance of a follow-up.
Children are more likely to be given a follow-up appointment (outpatient/physiotherapy) if they are
They are also more likely to have a follow-up appointment if they attended
an emergency department
on a weekend
at nighttime
Those attending in more recent years were less likely to have a follow-up appointment, even after attempting to adjust for case-mix, further indicating there has been a move towards fewer follow-up appointments.
Percentage of fractures manipulated in the ED
The percentage of forearm fractures manipulated in the emergency department has increased over the last 5 years, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.
The percentage of tibia/fibula fractures manipulated in the emergency department has also increased, but there is little change in the other fracture types over time.
Percentage of fractures manipulated in theatre
The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 5 years (by over 50%), with a greater percentage of fractures manipulated in theatre during the summer months.
The percentage of tibia/fibula fractures manipulated in theatre as also decreased.
Proportion of fractures manipulated
The total number of forearm fractures being manipulated either in the emergency department or theatre has decreased by 22% in the last 5 years.
Proportion of fractures manipulated in ED vs theatre
Over the last 5 years the proportion of manipulations that are performed in theatre has decreased mostly notably for forearm fractures where now over half of all manipulations are performed in the emergency department.
Use of emergency depts vs urgent treatment/walk-in centres
The number of fractures seen in emergency departments is relatively stable over time, however there is an increase in fractures being seen in urgent treatment/walk-in centres, although this may be an artefact of improved recording of fracture attendances in urgent treatment/ walk-in centres.
Manipulations, following ED or UTC attendance (2022/23)
A greater proportion of those attending emergency departments, compared to urgent treatment centres, have their fractures manipulated in the emergency department, which is to be expected given that manipulations would generally not be done within an urgent treatment centres.
However, the percentage of fractures manipulated in theatre is also higher for those attending emergency departments, suggesting those with more obvious/complex fractures that require manipulation are more likely to attend emergency departments, or be sent there from urgent treatment centres (in a small number of cases where a child attended 2 emergency care sites on the same day, we have only included the second attendance).
In 2022/23, 73% of fractures were seen in the emergency department, and 27% in urgent treatment centres.
However, 90% of fractures requiring manipulations were seen in the emergency department and around 10% in urgent treatment centres, further indicating that those with fractures that require manipulation are more likely to attend an emergency department rather than an urgent treatment centre.
:::
Follow-up appts following ED or UTC attendance (2022/23)
The percentage of fractures where a follow-up appointment is given is broadly similar at urgent treatment centres and emergency departments.
Factors influencing manipulation of forearm fractures in theatre
| Odds Ratio | Confidence Intervals | P value |
|---|
|
(Intercept) | 5.87 | 5.29 to 6.52 | <0.001* |
Sex |
Female | 1.00 |
| Reference |
Male | 0.93 | 0.88 to 0.99 | 0.01* |
Age |
5-10 yrs | 1.00 |
| Reference |
0-4 yrs | 1.62 | 1.48 to 1.77 | <0.001* |
11-16 yrs | 0.51 | 0.48 to 0.54 | <0.001* |
Ethnicity |
White | 1.00 |
| Reference |
Asian or Asian British | 0.81 | 0.73 to 0.91 | <0.001* |
Black or Black British | 0.49 | 0.41 to 0.59 | <0.001* |
Mixed | 0.69 | 0.6 to 0.8 | <0.001* |
Other Ethnic Groups | 0.54 | 0.46 to 0.62 | <0.001* |
Missing/Unknown | 0.85 | 0.78 to 0.93 | <0.001* |
IMD Quintiles |
1- Most deprived | 1.00 |
| Reference |
2 | 0.76 | 0.7 to 0.82 | <0.001* |
3 | 0.71 | 0.66 to 0.77 | <0.001* |
4 | 0.68 | 0.63 to 0.74 | <0.001* |
5- Least deprived | 0.62 | 0.57 to 0.67 | <0.001* |
Department type |
Major Emergency Department | 1.00 |
| Reference |
Urgent Treatment Centre/Walk in centre | 5.12 | 4.58 to 5.74 | <0.001* |
Day of the week |
Week | 1.00 |
| Reference |
Weekend | 1.09 | 1.03 to 1.15 | <0.001* |
Time of day |
Day 7am-7pm | 1.00 |
| Reference |
Night 7pm to 7am | 1.12 | 1.04 to 1.2 | <0.001* |
Time of year |
Autumn | 1.00 |
| Reference |
Winter | 0.87 | 0.8 to 0.95 | <0.001* |
Spring | 1.06 | 0.99 to 1.14 | 0.09 |
Summer | 1.17 | 1.09 to 1.25 | <0.001* |
Year |
2019/20 | 1.00 |
| Reference |
2020/21 | 0.43 | 0.4 to 0.47 | <0.001* |
2021/22 | 0.41 | 0.38 to 0.45 | <0.001* |
2022/23 | 0.28 | 0.26 to 0.3 | <0.001* |
2023/24 | 0.20 | 0.18 to 0.22 | <0.001* |
Logistic regression was used to allow us to identify which characteristics and thus which groups of children are more or less likely to have their forearm fracture manipulated in theatre.
Includes only forearm fractures that are manipulated, either the emergency department or in theatre (excludes those where manipulation is recorded in both ED and theatre) to determine what factors might be influencing the decision to manipulate a fracture in theatre rather than in the emergency department.
Children are more likely to have a fracture manipulated in theatre if they are
They are also more likely to have a manipulation in theatre if they attended
Those attending in more recent years were less likely to have their fracture manipulated in theatre, even after attempting to adjust for case-mix, further indicating there has been a move towards manipulating more fractures in the emergency department.
Summary of management of fractures
- For upper limb fractures there has been a slight reduction in the number given a follow up appointment. For all fracture types there there has been a significant increase in the proportion of follow-up appointments conducted virtually since the pandemic.
- Those presenting at night and at weekends were more likely to have follow up appointments and have their fracture manipulated in theatre. While it may be that those with more obvious/complex fractures that require manipulation/follow-up are more likely to present at these times, rather than perhaps waiting until the next day, it may also be the result of less senior staff available at these times.
- There has been a decrease post-pandemic in the number of outpatient procedures involving casts/splints/bandages and a decrease in diagnostic imaging in outpatients.
- Over the last 5 years the proportion of fractures manipulated in theatre has decreased and the proportion manipulated in the emergency department has increased.
- Those attending urgent treatment centres are more likely to have their fractures manipulated in theatre as this would generally not be possible at urgent treatment centres. Although the majority of fractures that require manipulation are seen in emergency departments.
- The overall manipulation rate for forearm fractures has reduced over the last 5 years, which likely reflects a change in the culture, with displaced fractures now less likely to be manipulated. Indeed, the CRAFFT study is currently looking at whether there is a difference in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.
- Overall, there is a trend towards more conservative management of paediatric fractures.
Opportunities to reduce hospital activity
We aimed to determine the scale of the potential opportunities to reduce hospital activity and costs if more conservative management of paediatric fractures is adopted.
It is not possible from the data to determine the most appropriate treatment at an individual patient level and exactly which activity could be reduced.
Some trusts are known to have adopted more conservative approaches to fracture management. Therefore, we have compared activity rates across trusts and calculated activity savings if all trusts reduced their levels of activity down to the level of the best performing trusts that may already be using more conservative management approaches.
Potential activity reductions considered:
reducing the percentage of emergency care attendances for toe and clavicle fractures where an x-ray is performed.
reducing the percentage of fractures where a follow-up outpatient appointment is given.
reducing the percentage of forearm and elbow fractures where a manipulation is performed in theatre.
For x-rays and outpatient attendances we have considered a reduction in activity down to the level of the lowest decile of trusts. However, for manipulations in theatre we have used the lowest quartile as there has already been a significant reduction in these over past 5 years and rates of manipulations in theatre are already low at many trusts.
Calculating proportions by trust
Includes only NHS trusts with 120+ attendances for fractures in 2022/23; this resulted in 8 trusts being excluded. Some trusts may have low numbers due to alternative provisions locally e.g. Royal Liverpool had small numbers which is unsurprising given its proximity to a specialist paediatric centre at Alder Hey. Independent providers were also excluded, the majority of these had small numbers of attendances for fractures (<120 per year).
Overall numbers and percentages for 2022/2023
| No. of fractures | X-ray in ED | Follow-up | Follow-up without procedure | Follow-up with procedure | Manipulated in theatre | Manipulated in ED | Manipulated in ED & theatre |
|---|
Clavicle | 15,119 | 13,149 (87%) | 9,171 (60.7%) | 8,388 (55.5%) | 783 (5.2%) | 8 (0.1%) | 10 (0.1%) | 0 (0%) |
Elbow | 21,840 | 19,193 (87.9%) | 17,704 (81.1%) | 13,658 (62.5%) | 4,046 (18.5%) | 258 (1.2%) | 177 (0.8%) | 12 (0.1%) |
Forearm | 71,844 | 62,679 (87.2%) | 46,217 (64.3%) | 35,550 (49.5%) | 10,667 (14.8%) | 3,024 (4.2%) | 2,686 (3.7%) | 222 (0.3%) |
Tibia/Fibula | 13,740 | 11,709 (85.2%) | 10,896 (79.3%) | 8,153 (59.3%) | 2,743 (20%) | 317 (2.3%) | 140 (1%) | 26 (0.2%) |
Toe | 14,604 | 11,117 (76.1%) | 6,406 (43.9%) | 5,830 (39.9%) | 576 (3.9%) | 9 (0.1%) | 177 (1.2%) | 1 (0%) |
When considering potential savings in terms of follow-up appointments, we have considered all follow-up appointments (with and without procedures).
X-rays for Clavicle and Toes fractures by trust
Evidence suggests that x-raying clavicle and toe fractures in the emergency department is often unnecessary, as it doesn’t add further useful information to a clinician’s assessment or alter management.
Percentage of clavicle fractures x-rayed
Min | 5.9 % |
1st quartile | 87.7 % |
Median | 93.2 % |
3rd quartile | 95.7 % |
Max | 100 % |
There would be an annual reduction in England of 1,986 (15.5%) x-rays in emergency care if all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (77.3%).
Percentage of toe fractures x-rayed
Min | 2.4 % |
1st quartile | 72.6 % |
Median | 82.4 % |
3rd quartile | 89.7 % |
Max | 100 % |
there would be an annual reduction in England of 2,412 (22.5%) x-rays in emergency care if all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (62.3%).
Cost of x-raying clavicle and toe fractures
All attendances at urgent treatment centres are costed at £85 regardless on whether a fracture is x-rayed.
For both clavicle and toe fractures without an x-ray the median cost of an emergency department attendance is £126 compared to a median cost of £184 when the fracture is x-rayed, suggesting a saving in the region of £58 for each clavicle or toe fracture not x-rayed in the emergency department.
Upper limb fractures with follow-up by trust (2022/23)
Min | 19.8 % |
1st quartile | 56.2 % |
Median | 65.1 % |
3rd quartile | 77.2 % |
Max | 98 % |
There would be an annual reduction in England of 13,768 (30.7%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (46%).
Min | 25.9 % |
1st quartile | 74.2 % |
Median | 83.6 % |
3rd quartile | 90.4 % |
Max | 100 % |
There would be an annual reduction in England of 4,486 (25.8%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (61.8%).
Min | 5.6 % |
1st quartile | 46.5 % |
Median | 61.2 % |
3rd quartile | 82.2 % |
Max | 97.4 % |
There would be an annual reduction in England of 4,440 (49.9%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (31.4%).
Lower limb fractures with follow-up by trust (2022/23)
Min | 20.2 % |
1st quartile | 72.8 % |
Median | 83.7 % |
3rd quartile | 90.1 % |
Max | 100 % |
There would be an annual reduction in England of 2,817 (26.4%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (60%).
Min | 11.1 % |
1st quartile | 31.7 % |
Median | 45.4 % |
3rd quartile | 56.9 % |
Max | 100 % |
There would be an annual reduction in England of 3,260 (53%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%).
Combining the potential reduction in the number of follow-up appointments for all of the fracture types included in this study, there could be a total annual reduction of 28,771 (33%) follow-up appointments in England.
This may be an underestimation as some children may have more than one follow-up appointment that could be deemed unnecessary.
Number of clavicle fracture follow-ups by trust (2022/2023)
This includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.
There is significant variability between trusts in the number of follow-up appointments for clavicle fractures.
Many clavicle fractures should not require follow-up yet some trusts are averaging 2-3 follow-up appointments per clavicle fracture, indicating a potential to further decrease follow-up appointments if second and subsequent appointments are considered.
Cost of face-to-face follow-up appointments
For all fracture types the median cost of the first face-to-face outpatient attendance is £175. Prices are not available for virtual follow-up appointments, although the costs will be reduced compared to face-to-face appointments.
Differences between our approach and the GIRFT metric
There are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study. GIRFT/Model Hospital:
include all forearm and wrist fractures, whereas we excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.
include re-manipulations in theatre, whilst we have excluded those coded as re-manipulations.
use a 3-year average, whilst we used only the most recent year where follow-up data is available (2022/23).
use the number of fractures manipulated in theatres taken directly from inpatient data and total A&E attendances for those aged 16 and under as the denominator. We have linked emergency care data to inpatient data and so are only considering manipulations in theatre for patients identified in the emergency care dataset as having a fracture.
The way the GIRFT metric is calculated means that it does not account for any regional differences in fractures rates, but it is unaffected by the poor recording of diagnoses codes in emergency care. Our measure accounts for regional differences, but does rely on the assumption that the fracture types requiring interventions and fractures that do not are equally likely have a diagnosis code recorded in emergency care, which may not always be the case.
Comparing methods for calculating the rate of manipulations
Graphs show our data for the number of forearm fractures manipulated in theatre in 2022/2023 (identified by linking to emergency care fracture records), but use different denominators to calculate the rate.
Top figure shows the 20 trusts with the highest (red) and 20 trusts with the lowest (green) rates of manipulations in theatre using total A&E attendances as the denominator.
Bottom figure uses the number of A&E attendances for forearm fractures as the denominator, and the same trusts labelled above are shown in their new positions according to this new metric. We have used this method to calculate manipulation rates in the subsequent slides, as it accounts for differences between trusts in the proportion of emergency department attendances that are for fractures. However, as diagnoses codes are not always recorded using this method we do have to make the assumption that the fractures that are recorded are representative to true case-mix.
Example 1, using total A&E attendances as the denominator The Royal Cornwall Hospitals Trust has a rate of ~16.6 forearm manipulations in theatre/10,000 A&E attendances, which puts it as the 11th highest rate in England. Using the number of forearm fractures as the denominator the manipulation rate of forearm fractures in theatre is 5.9%, moving The Royal Cornwall Hospitals Trust out of the highest quartile down to 43rd highest.
Example 2, Chelsea and Westminster Hospital NHS Foundation trust has a rate of 1.3 forearm manipulations in theatre/10,000 A&E attendances, which is the 16th lowest rate in England. However, when the number of forearm fractures is used as the denominator the rate of forearm manipulations in theatre is 6%, suggesting the trust doesn’t actually perform as well as first thought, moving it to the 42nd highest, with a similar rate to The Royal Cornwall Hospitals Trust.
Forearm fractures manipulated in theatre by trust (2022/23)
Min | 0.2 % |
1st quartile | 2.3 % |
Median | 4.4 % |
3rd quartile | 6.5 % |
Max | 21.4 % |
There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).
Elbow fractures manipulated in theatre by trust (2022/23)
NOTE: Very low numbers at many providers
Min | 0 % |
1st quartile | 0.5 % |
Median | 1.3 % |
3rd quartile | 2 % |
Max | 8.8 % |
There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%). This size of reduction is unlikely to have a significant impact in freeing up theatre time.
Cost of manipulations in the emergency department vs theatre
Those not manipulated in the emergency department are those that are manipulated but in theatre.
| Median cost of ED attendance with manipulation (£) | Median cost of ED attendance without manipulation (£) | Calculated cost of manipulation in ED (£) | Median cost of manipulation in theatre (£) | Potential saving per manipulation in ED (£) |
|---|
Forearm | 288 | 184 | 104 | 1,951 | 1,847 |
Elbow | 288 | 184 | 104 | 2,231 | 2,127 |
In addition to the cost savings, manipulating more fractures in the emergency department would free up theatre time.
Sites from CRAFFT study (2023/24)
Manipulations of forearm fractures in theatre
Trusts with hospitals participating in the CRAFFT study1 are shown in black; it can be seen that they are fairly evenly spread relative to other hospital sites, and aren’t clustered towards the lower end.
It should be noted that this chart is showing data from the most recent year, 2023-24, rather than 2022/23 which was used for the previous analysis.
Summary of the potential activity reductions
There is scope for a 19% reduction in the number of x-rays for clavicle and toe fractures in emergency care in England, equivalent to at least 4,400 x-rays per year.
The number of follow-up appointments for forearm, elbow, clavicle, tibia/fibula and toe fractures could be reduced by 33%, equivalent to at least 28,800 follow-ups per year in England. This is based on reducing the number of first follow-ups, but it appears a number of children have more than one unnecessary follow-up so this is likely an underestimate of the potential savings.
The number of forearm and elbow fractures manipulated in theatre could be reduced by an additional 55%, equivalent to a reduction of 1,900 manipulations in theatre in England per year. Assuming manipulation of a forearm/elbow fracture takes on average 45 mins1,2, this equates to 8.5 weeks of theatre time per year.
While some trusts have already implemented more conservative management approaches, particularly for manipulations, there appear to be some trusts that could still significantly benefit from adopting this approach. At many trusts there is significant scope to reduce number of x-rays performed for fractured clavicles and toes and the number of follow-up appointments for all fracture types.
| Clavicle | Elbow | Forearm | Tibia/Fibula | Toe | Total |
|---|
Reduction in x-rays in emergency care | 1,986 (15.5%) | - | - | - | 2,412 (22.5%) | 4,398 (18.7%) |
Reduction in follow-up appts | 4,440 (49.9%) | 4,486 (25.8%) | 13,768 (30.7%) | 2,817 (26.4%) | 3,260 (53%) | 28,771 (32.7%) |
Reduction in manipulations in theatre | - | 177 (67%) | 1,747 (54.5%) | - | - | 1,924 (55.4%) |
- Betham C et al. (2011) Manipulation of simple paediatric forearm fractures: a time-based comparison of emergency department sedation with theatre-based anaesthesia. N Z Med J. 124(1344):46-53.
- Seefried S et al (2022) Paediatric forearm fractures manipulated in the emergency department: incidence and risk factors for re-manipulation under general anaesthesia. N Z Med J. 135(1560):60-66.
Discussion
In agreement with previous studies we find forearm fractures are the most common followed by elbow fractures, and also higher fractures incidences in the summer and older boys due to higher levels of physical activity1,2. We find geographical variation in the recorded incidences of fractures in emergency care, some of this is likely the result of poor recording of fractures in emergency care in some areas. However, a previous paper found significant geographical variation with lower rates in London, similar to our results1. It is thought that regional variation may be due to levels of physical activity, obesity levels and the ethnic make up of the area; fracture rates were found to be higher in white children compared to those of black or South Asian ethnicity and to correlate with obesity and levels of physical activity1.
In the Paediatric Trauma and Orthopaedic Surgery GIRFT report it was suggested that there was scope to reduce the number of paediatric forearm manipulations in theatre by 80%3. That study used data from 2016-2019, in our study we have found since 2019/2020 the proportion of forearm fractures manipulated in theatre has fallen by 54%, from just over 8% in 2019/20 to under 4% in 2023/24.
It appears that there is the possibility to further reduce manipulations in theatre, particularly at some trusts, although overall at a national level the decrease in manipulation in theatre is likely to start slowing as the numbers get smaller. The switch to manipulating more fractures in the emergency department rather than in theatre will not only would save the NHS money, operating theatre time and resources, but will improve care for children and their families as treatment is quicker and less disruptive.
As highlighted within the Paediatric Trauma and Orthopaedic Surgery GIRFT report there are a number of factors that may be reduce the proportion of manipulations in the emergency department, including concerns about breach times, a lack of space/facilities to perform sedation, and a lack of familiarity with techniques3. Concerns around litigation may also lead to less conservative management, especially with elbow fractures which can lead to rare, but severe, complications. It is possible factors related to culture, lack of experience and litigation may also influence conservative management when it comes to reducing x-rays for clavicle and toe fractures and reducing follow-up appointments.
Nottingham University Hospitals NHS Trust, who are known to utilise more conservative management of paediatric fractures including routinely manipulating forearm fractures in the emergency department3,4, have, as expected, one of the lowest proportions of forearm fractures manipulated in theatre. In 2022/2023 only 0.5% of forearm fractures were manipulated in theatre (while 11.81% were manipulated in the emergency department) meaning only 4% of all forearm fractures requiring manipulation were performed in theatre. In terms of follow-up appointments 57% of forearm fractures receive a follow-up appointment, which is just above the lowest quartile.
- Moon RJ et al (2016) Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom. Bone. 85:9-14
- Mamoowala N et al (2019) Trends in paediatric distal radius fractures: an eight-year review from a large UK trauma unit. Ann R Coll Surg Engl. 101(4):297-303
- Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
- Bryson D et al. (2016) The lost art of conservative management of paediatric fractures. Bone Joint 360. 5(1):2-8.
Discussion (continued)
While at a national level the scope for significant further reductions in manipulations in theatre is likely to become limited, there is perhaps more scope in the future to reduce activity in terms of reducing unnecessary x-rays in the emergency department for clavicle and toe fractures, and in reducing the number of follow-up appointments.
The total number of forearm fractures that are manipulated has been decreasing, and there is perhaps scope for this to decrease further. Indeed, the CRAFFT study being conducted at over 45 sites in England is investigating whether there are any differences in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.
The GIRFT report found some trusts have moved towards splinting fractures in the emergency department with a virtual follow-up, rather than a temporary cast and then referral to a fracture clinic1. From our data the use of virtual follow-ups appears widespread, but there may be scope to reduce virtual appointments, especially as some trusts with high overall follow-up rates have a particularly high number of virtual appointments.
Evidence suggests that many x-rays of clavicle fractures are unnecessary as they tend to not add significantly to a clinician’s assessment or alter management2. However, almost all trusts still are x-raying the vast majority of potential clavicle fractures so the proportion of x-rays is still high even for the lowest decile of trusts (77%). Therefore our numbers are likely to be an underestimate of what activity savings could be potentially achieved. The same is likely true for toe fractures. It has been found that while most more experienced clinicians were comfortable treating clavicle fractures without x-rays, more junior clinicians were not2.
Our absolute number estimates of reductions in activity may be an underestimate, because diagnoses are not reliably being recorded by some trusts in the emergency department. It is also possible that there may be some bias on the types of fractures attending emergency care that are given a diagnosis code. For example, it is possible at trusts that do not consistently record diagnosis codes in emergency care may be more likely to record fractures requiring manipulation than those that do not require manipulation or follow-up. However, when looking at trusts there was no significant relationship between the proportion of emergency care attendances without diagnosis codes and the proportion of fractures manipulated in theatre.
This report does highlight the need for more accurate and consistent recording of diagnoses in emergency care.
- https://crafft-study.digitrial.com/
- Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304
Limitations
We are relying on the coding/reporting of fractures, manipulations, x-rays and outpatient appointments within the the SUS datasets. Some of the variability in the number of fractures, x-rays, physiotherapy referrals, follow-up appointments and manipulations between trusts and over time could be due to issues with the coding.
As diagnosis code is not always recorded in the emergency care dataset our incidence rates give the incidence of fractures recorded in emergency care, and only include closed fractures, open fractures were excluded.
The coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts, but but we can’t be sure whether all trusts have a similar proportion of more complex fractures that do require manipulation and follow-up.
There will be a small number of cases where a child has more than one fracture or other injuries recorded in emergency care (<1%), so it is possible any follow-up appointments or manipulations could potentially be for a different injury/fracture sustained at the same time.
Data is allocated to the trust where the child attended the emergency department, e.g. if a child first attended the emergency department at trust A while on holiday but subsequently received follow-up appointments at trust B the fracture and subsequent follow-up would be included in the data for trust A.
The number of elbow manipulations recorded in theatre appears lower than would be expected, which may be due to coding issues. The lack of detailed coding of fractures makes it difficult to determine what is an elbow fracture and may mean that some are classified as forearm fractures, e.g. the SNOMED code for ‘Closed fracture of radius (disorder)’ is the most commonly used, and while we have classified these as forearm fractures, fractures of the proximal radius would be considered an elbow fracture. This may in part explain why we see a smaller number of elbow manipulations in theatre than would be expected, as they are included within forearm fractures. Also, HRG groupings for manipulations in theatre do not distinguish between forearm and elbow procedures, so it is not possible to determine from these which are forearm and which are elbow manipulations. We have only considered elbow manipulations in theatre that could be conducted in the emergency department, i.e. those without internal fixation such as wires or pins. Therefore our elbow manipulation number might also be affect by the propensity of individual trusts to use internal fixation for elbow fractures. We have also not included re-manipulations in our data.
These potential reductions in activity are for England only, but there is likely also the potential for activity savings in the other countries of the UK.
Cost savings are calculated from HRG prices and are only indicative estimates of potential cost savings.
Future work
To fully understand the potential cost savings of these reductions in activity a full health economic analysis would be required.
It may be helpful to do some more detailed mapping and analysis of patient pathways to better understand how fractures are being managed, and where further activities savings could be made with more conservative management.
There are currently trends towards more conservative management, particularly regarding increasing manipulations in the emergency department, so there is scope to investigate the extent to which these trends could continue and further activity can be reduced.
Future work could also focus on understanding the degree in variation between trusts in the proportion of forearm and elbow fractures that are manipulated in theatre with the use of internal fixation, and whether there are fractures that could be manipulated without the need for internal fixation.
Appendix A- Forearm and Clavicle fracture SNOMED codes
Forearm
208388003 | Fracture at wrist and/or hand level (disorder) |
209264008 | Closed fracture dislocation of wrist (disorder) |
209265009 | Closed fracture dislocation distal radioulnar joint (disorder) |
209284007 | Closed fracture subluxation of distal radioulnar joint (disorder) |
67730008 | Closed Bennett's fracture (disorder) |
307713000 | Closed Barton's fracture (disorder) |
208324004 | Closed dorsal Barton's fracture (disorder) |
208323005 | Closed volar Barton's fracture (disorder) |
209283001 | Closed fracture subluxation of the wrist (disorder) |
263102004 | Fracture subluxation of wrist (disorder) |
61653009 | Bennett's fracture (disorder) |
263103009 | Fracture subluxation of distal radioulnar joint (disorder) |
1290784005 | Stress fracture of bone of wrist region (disorder) |
1303397005 | Fracture of bone of wrist region (disorder) |
1285722006 | Fracture of distal end of left ulna (disorder) |
14430001000004100 | Fracture of distal end of right ulna (disorder) |
27094009 | Skillern's fracture (disorder) |
281530009 | Fracture of ulnar styloid (disorder) |
41036008 | Closed fracture of styloid process of ulna (disorder) |
263208005 | Fracture of distal end of radius and ulna (disorder) |
33192001 | Closed fracture of lower end of radius AND ulna (disorder) |
50397009 | Closed fracture of distal end of ulna (disorder) |
208318005 | Closed fracture of ulna, lower epiphysis (disorder) |
6163002 | Closed fracture of head of ulna (disorder) |
263199001 | Fracture of distal end of radius (disorder) |
58722007 | Moore's fracture (disorder) |
448355005 | Greenstick fracture of distal radius (disorder) |
737262009 | Fracture of lower end of radius with volar tilt (disorder) |
737261002 | Fracture of lower end of radius with dorsal tilt (disorder) |
123972004 | Reversed Colles' fracture (disorder) |
123618009 | Closed reverse Colles' fracture (disorder) |
281527002 | Fracture of radial styloid (disorder) |
208325003 | Closed fracture radial styloid (disorder) |
426467005 | Hutchinson's fracture (disorder) |
18310001000004100 | Fracture of distal end of right radius (disorder) |
16542901000119100 | Closed fracture of metaphysis of distal end of right radius (disorder) |
1285724007 | Fracture of distal end of left radius (disorder) |
16542861000119100 | Closed fracture of metaphysis of distal end of left radius (disorder) |
123971006 | Colles' fracture (disorder) |
269083002 | Closed Colles' fracture (disorder) |
17222009 | Closed fracture of distal end of radius (disorder) |
448838000 | Closed extraarticular fracture of distal radius (disorder) |
208326002 | Closed fracture distal radius, intra-articular, die-punch (disorder) |
704212006 | Closed fracture of distal epiphysis of radius (disorder) |
1279881008 | Closed fracture of metaphysis of distal end of radius (disorder) |
35442005 | Closed fracture of lower end of forearm (disorder) |
307172007 | Fracture dislocation distal radioulnar joint (disorder) |
1264544004 | Fracture of bone adjacent to prosthesis of wrist joint (disorder) |
12217801000119100 | Fracture of bone adjacent to prosthesis of left wrist joint (disorder) |
12202711000119100 | Fracture of bone adjacent to prosthesis of right wrist joint (disorder) |
1303394003 | Fracture of bone of left wrist region (disorder) |
1303396001 | Fracture of bone of bilateral wrist regions (disorder) |
1303395002 | Fracture of bone of right wrist region (disorder) |
46773004 | Quervain's fracture (disorder) |
3228009 | Closed fracture of shaft of radius (disorder) |
12676007 | Fracture of radius (disorder) |
28078000 | Closed fracture of shaft of bone of forearm (disorder) |
53627009 | Closed fracture of radius AND ulna (disorder) |
53792000 | Closed fracture of shaft of ulna (disorder) |
54556006 | Fracture of ulna (disorder) |
54645004 | Barton's fracture (disorder) |
54819005 | Closed fracture of shaft of radius and ulna (disorder) |
65966004 | Fracture of forearm (disorder) |
71555008 | Closed fracture of ulna (disorder) |
75857000 | Fracture of radius AND ulna (disorder) |
91419009 | Closed fracture of forearm (disorder) |
111640008 | Closed fracture of radius (disorder) |
208309008 | Closed fracture radius and ulna, middle (disorder) |
208322000 | Closed Galeazzi fracture (disorder) |
208513000 | Multiple fractures of forearm (disorder) |
263198009 | Fracture of shaft of radius (disorder) |
263200003 | Volar Barton's fracture (disorder) |
263201004 | Dorsal Barton's fracture (disorder) |
263204007 | Fracture of shaft of ulna (disorder) |
263205008 | Fracture of distal end of ulna (disorder) |
263207000 | Fracture of shaft of radius and/or ulna (disorder) |
268824003 | Fracture of radius and/or ulna due to birth trauma (disorder) |
271576001 | Galeazzi fracture dislocation (disorder) |
281528007 | Fracture of olecranon (disorder) |
281529004 | Fracture of coronoid process of ulna (disorder) |
287074009 | Fracture malunion - forearm (disorder) |
390986009 | Torus fracture of radius (disorder) |
429655000 | Closed torus fracture of radius (disorder) |
704056001 | Stress fracture of ulna (disorder) |
704059008 | Stress fracture of radius (disorder) |
733235002 | Fracture of shaft of ulna and radius (disorder) |
1285721004 | Fracture of right ulna (disorder) |
1303390007 | Fracture of bone of left forearm (disorder) |
1303391006 | Fracture of bone of right forearm (disorder) |
446461000124103 | Fracture of right radius (disorder) |
12960001000004100 | Fracture of left radius (disorder) |
13270001000004100 | Fracture of left ulna (disorder) |
Clavicle
58150001 | Fracture of clavicle |
33173003 | Closed fracture of clavicle |
1658003 | Closed fracture of acromial end of clavicle |
87376003 | Closed fracture of shaft of clavicle |
48561006 | Closed fracture of sternal end of clavicle |
88196000 | Fracture of interligamentous part of clavicle (disorder) |
1303380004 | Fracture of left clavicle (disorder) |
1303379002 | Fracture of bone of bilateral clavicles (disorder) |
1303381000 | Fracture of right clavicle (disorder) |
41972004 | Fracture of shaft of clavicle (disorder) |
56642004 | Fracture of sternal end of clavicle (disorder) |
733403004 | Multiple fractures of clavicle (disorder) |
208510002 | Multiple fractures of clavicle, scapula and humerus (disorder) |
431011000 | Nonunion of fracture of clavicle (disorder) |
704069002 | Stress fracture of clavicle (disorder) |
Appendix B- Elbow fracture SNOMED codes
Elbow
123973009 | Monteggia's fracture (disorder) |
1303382007 | Fracture of left olecranon (disorder) |
1303383002 | Fracture of right olecranon (disorder) |
1303392004 | Fracture of bone of left elbow joint region (disorder) |
1303393009 | Fracture of bone of right elbow joint region (disorder) |
16866431000119100 | Closed fracture of capitellum of right humerus (disorder) |
16867081000119100 | Closed fracture of capitellum of left humerus (disorder) |
19259001 | Closed fracture of upper end of radius AND ulna (disorder) |
208267005 | Closed fracture distal humerus, lateral condyle (disorder) |
208270009 | Closed fracture of distal humerus, trochlea (disorder) |
208271008 | Closed fracture distal humerus, lateral epicondyle (disorder) |
208272001 | Closed fracture distal humerus, capitellum (disorder) |
208273006 | Closed fracture distal humerus, bicondylar (T-Y fracture) (disorder) |
208274000 | Multiple closed fractures of distal humerus (disorder) |
208294009 | Closed fracture olecranon, extra-articular (disorder) |
208295005 | Closed fracture of proximal ulna, comminuted (disorder) |
208296006 | Closed fracture proximal radius, comminuted (disorder) |
208298007 | Closed fracture olecranon, intra-articular (disorder) |
209252000 | Closed fracture dislocation elbow joint (disorder) |
209253005 | Closed fracture dislocation superior radioulnar joint (disorder) |
209258001 | Closed fracture subluxation of elbow joint (disorder) |
209259009 | Closed fracture subluxation superior radioulnar joint (disorder) |
21419000 | Closed fracture of medial condyle of humerus (disorder) |
2295008 | Closed fracture of upper end of forearm (disorder) |
263078002 | Fracture dislocation of elbow joint (disorder) |
263100007 | Fracture subluxation of elbow joint (disorder) |
263101006 | Fracture subluxation of superior radioulnar joint (disorder) |
263192005 | Fracture of distal end of humerus (disorder) |
263193000 | Supracondylar fracture of humerus (disorder) |
263195007 | Fracture of proximal end of radius (disorder) |
263196008 | Fracture of radial head (disorder) |
263197004 | Fracture of radial neck (disorder) |
263203001 | Fracture of proximal end of ulna (disorder) |
263206009 | Fracture of proximal end of radius and ulna (disorder) |
269080004 | Closed fracture of the distal humerus (disorder) |
281525005 | Fracture of the lateral humeral epicondyle (disorder) |
281526006 | Fracture of the medial humeral epicondyle (disorder) |
29045004 | Closed Monteggia's fracture (disorder) |
302222008 | Elbow fracture - closed (disorder) |
309464009 | Elbow fracture (disorder) |
33041006 | Closed fracture of proximal end of ulna (disorder) |
440366004 | Closed fracture of the medial epicondyle of humerus (disorder) |
441496000 | Transcondylar fracture of distal humerus (disorder) |
442448003 | Fracture of head of radius with dislocation of distal radioulnar joint and interosseous membrane disruption (disorder) |
58580000 | Closed supracondylar fracture of humerus (disorder) |
5895007 | Closed multiple fractures of upper end of radius (disorder) |
64902007 | Closed fracture of olecranon process of ulna (disorder) |
68819003 | Closed fracture of coronoid process of ulna (disorder) |
68854005 | Closed fracture of head of radius (disorder) |
700147004 | Avulsion fracture of medial epicondyle of humerus (disorder) |
704208000 | Closed fracture of proximal epiphysis of radius (disorder) |
704410001 | Closed transcondylar fracture of distal humerus (disorder) |
705076001 | Closed fracture of epiphyseal plate of distal humerus (disorder) |
71139009 | Closed fracture of proximal end of radius (disorder) |
72497001 | Closed fracture of neck of radius (disorder) |
733408008 | Fracture of lateral condyle of humerus (disorder) |
733409000 | Fracture of medial condyle of humerus (disorder) |
7341005 | Closed multiple fractures of upper end of ulna (disorder) |
80767005 | Closed fracture of condyle of humerus (disorder) |
Appendix C- Tibia/Fibula and Toe fracture SNOMED codes
Tibia/Fibula
31978002 | Fracture of tibia (disorder) |
6698000 | Closed trimalleolar fracture (disorder) |
6990005 | Fracture of shaft of tibia (disorder) |
15385006 | Closed fracture of medial malleolus (disorder) |
20433007 | Fracture of upper end of tibia (disorder) |
23900009 | Closed fracture of upper end of tibia (disorder) |
25899002 | Closed bimalleolar fracture (disorder) |
28012007 | Closed fracture of shaft of tibia (disorder) |
47848000 | Closed fracture of condyle of tibia (disorder) |
71830006 | Supination-adduction injury of ankle, stage 2 (disorder) |
87905008 | Gosselin's fracture (disorder) |
123975002 | Trimalleolar fracture (disorder) |
208610006 | Closed fracture proximal tibia, medial condyle (plateau) (disorder) |
208611005 | Closed fracture proximal tibia, lateral condyle (plateau) (disorder) |
208612003 | Closed fracture proximal tibia, bicondylar (disorder) |
208613008 | Closed fracture intercondylar spine of tibia (disorder) |
208629000 | Closed fracture of tibia and fibula, shaft (disorder) |
208634001 | Closed fracture distal tibia (disorder) |
208635000 | Closed fracture distal tibia, extra-articular (disorder) |
208636004 | Closed fracture distal tibia, intra-articular (disorder) |
208662008 | Closed fracture ankle, bimalleolar, low fibular fracture (disorder) |
208663003 | Closed fracture ankle, bimalleolar, high fibular fracture (disorder) |
208666006 | Closed fracture ankle, trimalleolar, low fibular fracture (disorder) |
208667002 | Closed fracture ankle, trimalleolar, high fibular fracture (disorder) |
263237009 | Closed fracture of tibial tuberosity (disorder) |
263240009 | Pilon fracture (disorder) |
263241008 | Tillaux fracture (disorder) |
263244000 | Bimalleolar fracture of ankle (disorder) |
271577005 | Fracture of shaft of tibia and fibula (disorder) |
278537006 | Fracture of distal end of tibia (disorder) |
281531008 | Fracture of medial malleolus (disorder) |
281532001 | Fracture of posterior malleolus (disorder) |
281843000 | Fracture of tibial spine (disorder) |
413877007 | Closed fracture of tibia AND fibula (disorder) |
414293001 | Fracture of tibia AND fibula (disorder) |
428256003 | Fracture of condyle of tibia (disorder) |
428257007 | Fracture of tibial plateau (disorder) |
428797006 | Closed osteochondral fracture of proximal tibia (disorder) |
428798001 | Closed fracture of tibial plateau (disorder) |
442205007 | Stress fracture of tibia (disorder) |
445410003 | Closed fracture of distal tibia and distal fibula (disorder) |
446298003 | Closed pilon fracture (disorder) |
447139008 | Closed fracture of tibia (disorder) |
703998005 | Closed bicondylar fracture of tibial plateau (disorder) |
705080006 | Closed fracture of epiphyseal plate of distal tibia (disorder) |
705092006 | Closed fracture of epiphyseal plate of proximal tibia (disorder) |
733295004 | Avulsion of tibial tuberosity (disorder) |
735669008 | Fracture of metaphysis of proximal tibia (disorder) |
735671008 | Fracture of lateral condyle of tibia (disorder) |
735672001 | Fracture of medial condyle of tibia (disorder) |
735846008 | Avulsion of ligament with bony fragment of medial malleolus (disorder) |
39541000087106 | Fracture of medial condyle of left tibia (disorder) |
39551000087109 | Fracture of medial condyle of right tibia (disorder) |
40031000087104 | Fracture of left tibial plateau (disorder) |
40041000087105 | Fracture of right tibial plateau (disorder) |
40051000087108 | Fracture of lateral condyle of left tibia (disorder) |
40061000087106 | Fracture of lateral condyle of right tibia (disorder) |
40071000087102 | Fracture of left medial malleolus (disorder) |
40081000087100 | Fracture of right medial malleolus (disorder) |
10924841000119100 | Closed fracture of medial condyle of right tibia (disorder) |
10924881000119100 | Closed fracture of medial condyle of left tibia (disorder) |
75591007 | Fracture of fibula (disorder) |
21867001 | Fracture of upper end of fibula (disorder) |
28359007 | Closed fracture of head of fibula (disorder) |
34268009 | Closed fracture of lateral malleolus (disorder) |
59639009 | Closed fracture of upper end of fibula (disorder) |
67394003 | Fracture of shaft of fibula (disorder) |
77803008 | Closed fracture of shaft of fibula (disorder) |
208615001 | Closed fracture fibula, neck (disorder) |
208657007 | Closed fracture ankle, lateral malleolus, low (disorder) |
208658002 | Closed fracture ankle, lateral malleolus, high (disorder) |
263242001 | Fracture of distal end of fibula (disorder) |
281533006 | Fracture of head of fibula (disorder) |
281534000 | Fracture of neck of fibula (disorder) |
281535004 | Fracture of lateral malleolus (disorder) |
308153009 | Closed fracture of distal fibula (disorder) |
315643003 | Dupuytren's fracture dislocation ankle (disorder) |
442538002 | Stress fracture of fibula (disorder) |
447395005 | Closed fracture of fibula (disorder) |
704209008 | Closed fracture of epiphysis of proximal fibula (disorder) |
705082003 | Closed fracture of epiphyseal plate of distal fibula (disorder) |
733296003 | Avulsion of head of fibula (disorder) |
735842005 | Fracture of lateral malleolus below syndesmosis (disorder) |
735844006 | Avulsion of ligament with bony fragment of lateral malleolus (disorder) |
735845007 | Fracture of lateral malleolus at syndesmosis (disorder) |
735847004 | Fracture of distal fibula above syndesmosis (disorder) |
736517000 | Avulsion fracture of anterior fibula (disorder) |
19350001000004100 | Stress fracture of tibia and fibula (disorder) |
Toe
21351003 | Fracture of phalanx of foot (disorder) |
81576005 | Closed fracture of phalanx of foot (disorder) |
302036006 | Closed fracture dislocation of interphalangeal joint of toe (disorder) |
209361003 | Closed fracture dislocation of interphalangeal joint of multiple toes (disorder) |
209378007 | Closed fracture subluxation of interphalangeal joint of multiple toes (disorder) |
209359007 | Closed fracture dislocation of interphalangeal joint of single toe (disorder) |
208712008 | Closed fracture distal phalanx, toe (disorder) |
705067008 | Closed fracture of distal phalanx of lesser toe (disorder) |
208711001 | Closed fracture middle phalanx, toe (disorder) |
705068003 | Closed fracture of epiphyseal plate of lesser toe (disorder) |
208713003 | Closed fracture of multiple phalanges of toe (disorder) |
208710000 | Closed fracture proximal phalanx, toe (disorder) |
704057005 | Stress fracture of phalanx of foot (disorder) |
11314801000119100 | Stress fracture of phalanx of left foot (disorder) |
11314761000119100 | Stress fracture of phalanx of right foot (disorder) |
263093003 | Fracture dislocation of toe joint (disorder) |
263117000 | Fracture subluxation of interphalangeal joint of toe (disorder) |
209375005 | Closed fracture subluxation of interphalangeal joint of single toe (disorder) |
Appendix D
Manipulations in emergency department were identified using A&E Treatment Code:
10- Reduction
Manipulations in theatre were identified by one of the following OPCS codes recorded during an inpatient episode in the 3 months post-emergency care attendance.
- W262 Manipulation of fracture of bone NEC
- W268 Other specified
- W269 Unspecified
- W663 Primary manipulative closed reduction of fracture dislocation of joint NEC
- W252 Closed reduction of fracture of bone and fixation using functional bracing system
X-rays in the emergency department were identified using A&E Investigation Code:
01- X-ray
Physiotherapy appointments were identified by one of the following:
- SNOMED referral code for physiotherapy in ECDS- 306170007 Referral to physiotherapy service (procedure)
- Treatment Function Code for physiotherapy in the outpatient dataset in the 3 months post-emergency care attendance- 650 Physiotherapy Service
Outpatient follow up appointments were identified using the following codes in the outpatient dataset in the 3 months post-emergency care attendance
Treatment function code was one of:
- 110 Trauma and Orthopaedic service
- 111 Orthopaedic Service
- 115 Trauma Surgery Service
- 214 Paediatric Trauma and Orthopaedic Service
Or 420 Paediatrics provided that the outpatient referral source was either: 10- initiated following an emergency care attendance (including minor injuries, walk in centres and urgent treatment centres) OR 04- not initiated following a referral from an emergency care department (including minor injuries, walk in centres and urgent treatment centres)
It was also required that the emergency care attendance discharge information did NOT have the SNOMED code- 3780001 Routine patient disposition, no follow-up planned (procedure)